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Difficulty: MediumAccident, Error, and Injury Prevention

A client recovering from a total hip arthroplasty begins experiencing sudden confusion and repeatedly attempts to get out of bed unassisted. The client's spouse is at the bedside and asks the practical nurse to physically secure the client to the bed to prevent a fall. Which statement by the nurse best promotes client safety and adheres to standard guidelines?

  1. We must first attempt less restrictive measures, such as using a bed alarm and frequent reorientation.Answer
  2. B
    I will contact the provider to request a mild sedative to calm the client and prevent wandering.
  3. C
    Sudden confusion is expected for older adults in the hospital, so we will raise all four side rails.
  4. D
    I can apply the restraints immediately if you sign the facility's informed consent form.

Answer

The correct response is to explain that less restrictive measures, such as a bed alarm, must be attempted first.
The correct response demonstrates adherence to safety protocols by prioritizing less restrictive measures, such as bed alarms and reorientation, before considering restraints.

Step-by-Step Solution

1
Analyze the clinical situation and the spouse's request.
The client is acutely confused and at risk for falls, and the spouse is requesting physical restraints.
Understanding the exact nature of the safety risk and the requested intervention is required to formulate an appropriate response.
2
Recall the standard guidelines for restraint use and accident prevention.
Guidelines mandate that physical and chemical restraints are a last resort.
Restraints can cause further injury or agitation. Less restrictive alternatives must be attempted and documented first.
3
Evaluate the nursing responses against the guidelines.
The option prioritizing bed alarms and reorientation aligns with the requirement to use the least restrictive measures.
This approach addresses the fall risk while maintaining the client's safety and dignity without immediately resorting to restraints.

Key Concept

Restraint Alternatives and Fall Prevention
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Topics

Accident, Error, and Injury Prevention

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